Forensic Sci Med Pathol (2011) 7:283–286 DOI 10.1007/s12024-010-9214-5
CASE REPORT
Aspiration pneumonia and esophagotracheal fistula secondary to button battery ingestion Delecia R. LaFrance • James G. Traylor Jr. Long Jin
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Accepted: 8 December 2010 / Published online: 9 February 2011 Ó Springer Science+Business Media, LLC 2011
Abstract We report a case of acute bronchopneumonia and esophagotracheal fistula caused by a swallowed button battery in a 3-year-old girl. It was unclear exactly how long the battery had been trapped in the esophagus. The patient had undergone a tonsillectomy and adenoidectomy 3 weeks before the battery was finally exposed on an X-ray film. She refused to eat solid food after the surgery and stopped eating completely 10 days later. Three weeks after surgery, she presented to the Emergency Department with vomiting and acute respiratory distress, experienced cardiopulmonary arrest in the intensive care unit and could not be resuscitated. Postmortem examination revealed severe acute bronchopneumonia and massive blood aspiration due to an esophagotracheal fistula secondary to a button battery lodged in the esophagus. This case highlights the importance of including a swallowed button battery in the differential diagnosis of a toddler with dysphagia and anorexia. Keywords Forensic science Button battery Esophagotracheal fistula Blood aspiration Bronchopneumonia Postmortem examination
D. R. LaFrance J. G. Traylor Jr. L. Jin (&) Department of Pathology, Louisiana State University Health Sciences Center-Shreveport, 1501 Kings Hwy, P.O. Box 33932, Shreveport, LA 71130-3932, USA e-mail:
[email protected] D. R. LaFrance e-mail:
[email protected] J. G. Traylor Jr. e-mail:
[email protected]
Introduction Button batteries are swallowed by over 2,100 people per year in the US, affecting mostly toddlers under the age of 5, with a peak incidence in 1- and 2-year olds [1]. Fortunately, most of these incidents resolve without medical intervention. In rare instances, particularly when the swallowed battery is of larger diameter (20–23 mm), the battery can become lodged in the esophagus necessitating medical attention [1–4]. We report a fatal incident in which a 3-year old girl swallowed a 20 mm button battery that resulted in the development of an esophagotracheal fistula with subsequent blood aspiration and acute bronchopneumonia. To date, only 19 cases of severe esophageal damage secondary to the ingestion of button batteries have been reported in the English literature, and only two have been fatal; our literature search revealed no such cases in the past 30 years [5, 6].
Case report The patient was a 3-year-old African American female with a history of obstructive sleep apnea that underwent tonsillectomy and adenoidectomy (T&A) 3 weeks prior to death. No excessive bleeding or other complications were documented at the time of surgery, and she was discharged in stable condition. The child’s mother stated that she tolerated only liquids during the weeks following surgery. Ten days post T&A; the patient developed a fever of 40°C. She was seen by her surgeon and was treated with antibiotics and cough syrup. Although her symptoms were improving, she was still unable to eat solid food. She visited her primary care physician 3 days later and Phenergan and Lortab elixir were added to soothe the pain, which was
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attributed to the recent surgery. Approximately 1 week later (3 weeks after surgery), the patient presented to the Emergency Department with vomiting and acute respiratory distress. At this time, she had a pulse oximetry reading of 94% on room air; her breathing was labored and she was tachypneic. A chest X-ray revealed diffuse bilateral infiltrates suggestive of bronchopneumonia, and more surprisingly, a coin like metallic object in the esophagus at the thoracic inlet (Fig. 1a). She was treated with antibiotics, intravenous fluid and DuoNeb aerosol and transferred to the Pediatric Intensive Care Unit. A gastroenterology consult was obtained and an upper endoscopy was scheduled to remove the foreign body on the next day. Later that afternoon, the patient developed coughing spells with marked hemoptysis. She was intubated and transfused with packed red blood cells (20 ml/kg) to correct for her blood loss. The patient remained stable until near midnight when she suddenly developed acute bradycardia with excessive bleeding from her mouth, nose and endotracheal tube. Her heart rate normalized after approximately 30 min of vigorous resuscitative effort, but her pupils were fixed, dilated and nonreactive. She developed another episode of massive hematemesis and expired after unsuccessful resuscitation attempts. An autopsy was performed at the Pathology Department of Louisiana State University Health Sciences CenterShreveport upon request by the local Coroner’s office.
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Postmortem external examination documented the decedent as an African American female weighing 33 lb. She measured 3 feet 2 inches with no evidence of physical abuse. Upon internal examination, a button battery was found lodged in the thoracic esophagus oriented in a vertical position (Fig. 1b). The battery measured 20 mm in diameter and 0.25 cm in thickness, with significant surface corrosion; engraved on the battery was ‘‘CR2032 3-volts Energizer ?’’ (Fig. 1c). A longitudinal fistula measuring 1 cm in length was identified between the anterior esophagus and posterior trachea at the battery-lodging site. The surrounding esophageal and tracheal mucosa appeared hyperemic and thickened, but not otherwise discolored. The lungs were engorged with a purple-red external ‘‘mosaic’’ pattern. The stomach contained 200 ml of blood clots and blood, with normal appearing underlying gastric mucosa and wall. The body cavities were free from excess fluid with no evidence of exsanguination. On light microscopy, hematoxylin and eosin (H&E) sections of the lungs revealed acute bronchopneumonia with congestion and blood-filled alveolar spaces (Fig. 2). Rare fragments of tiny refractile foreign body material were identified in the lung. In the trachea near the fistula, sloughed respiratory epithelial lining cells, mixed inflammatory infiltrate (composed of eosinophils, lymphocytes and histiocytes), vascular congestion, and granulation tissue were identified (Fig. 3a). Sections of esophagus revealed an esophageal fistula with extensive granulation tissue and necrosis, dense inflammation, and yellow– brown, refractile Prussian blue positive material consistent with iron (Fig. 3b). Given the clinical history, autopsy and microscopic findings, the cause of death was determined to be the ‘‘combined effect of bronchopneumonia and blood aspiration as the complication of partial blockage of the upper respiratory tract by a battery coin lodged in the esophagus.’’ The manner of death was accidental. Efforts to obtain additional information on how and when the battery was swallowed and further elucidate the exact sequence of events were unsuccessful.
Discussion
Fig. 1 Admission chest X-ray revealing an esophageal foreign body (arrow) and EKG leads (*) (a). Longitudinal esophagotracheal fistula with metallic button battery (arrow) lodged in esophagus (b). CR2032 3-volt Energizer ? button battery retrieved from esophagus (c)
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Historically, cases of foreign body ingestion have been treated using emetics; however, this approach is no longer recommended due to ineffectiveness and increased potential for retrograde movement, esophageal lodgment, or aspiration. Although there is no consensus in management, current research suggests that an initial roentgenogram be performed [1, 3]. As observed in Fig. 1a, EKG leads are of similar size and density as the lodged metal object and may be mistakenly overlooked as artifact; therefore, X-rays
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Fig. 2 Hematoxylin and eosin-stained section of the lung showing acute bronchopneumonia at 109 magnification (a) and blood-filled alveolar spaces at 209 magnification (b)
should be interpreted by physicians or skilled technicians in concert with clinical information and patient observation to avoid this oversight. In evaluating the initial X-ray, it is particularly important to document the location of the battery, which dictates further patient management. Watchful waiting (with or without serial roentgenographic localization) is an acceptable alternative for objects not impacted in the esophagus, although endoscopic removal of non-esophageal objects may be required in rare instances. However, surgical removal is seldom indicated, as most ingestion cases without esophageal impaction resolve without complication [1, 7]. Alternatively, foreign bodies impacted in the esophagus should be removed expeditiously due to their risk of serious complications which may include pressure necrosis, foreign body reaction, fistulation, or respiratory compromise. Additionally, the course of events is highly dependent on the size and nature of the impacted item. For example, an impacted battery (vs. a coin of similar size) is more dangerous because of its corrosive center which may
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Fig. 3 Hematoxylin and eosin-stained section of tracheal mucosa with epithelial sloughing, inflammation, congestion and granulation tissue at 109 magnification (a). Hematoxylin and eosin-stained section of esophageal mucosa with foreign body material (arrow), granulation tissue, necrosis, and inflammation at 109 magnification. Inset shows foreign body material is Prussian blue positive, consistent with iron, 209 magnification (b)
leak over time as a result of acid-induced surface damage. In our case, it is proposed that the battery was large enough to enter the esophagus but too large to pass through the lower esophageal sphincter. Therefore, it became impacted in the esophagus resulting in focal pressure necrosis, inflammation, and subsequent superficial corrosion of the metal casing by refluxed gastric acid. After an undetermined period of time, this combination of effects eventually incited fistula formation, subsequent development of bronchopneumonia and aspiration of blood. More important than the treatment of such cases is the implementation of preventative measures. Therefore, a proactive approach to increase awareness and public education on the dangers of battery ingestion is of foremost importance. Additional preventative measures, such as inclusion of such dangers in childproofing guidelines, and manufacturing securely fastened, child-resistant battery compartments on hearing aids and other battery-powered
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products may also be deemed effective in minimizing the incidence of swallowed button batteries. In the event that medical attention is sought for a toddler with dysphagia and anorexia, it is important that physicians have a heightened index of suspicion and evaluate the patient thoroughly. As with our case, X-ray examination may reveal an esophageal button battery, thereby allowing for prompt treatment. Furthermore, upon identification of the impacted foreign body, emergent endoscopy may be warranted. Despite its rare occurrence, this unique case highlights several key points regarding the hazards associated with impacted foreign bodies, particularly of ingested button batteries. First, parents should be aware of such dangers and seek medical attention if they have any suspicion that their child has swallowed a battery. Secondly, because of the potentially fatal consequences of ingested button batteries with esophageal impaction, it is important for treating physicians to keep this condition in their list of differential diagnoses when assessing patients with dysphagia and anorexia. Finally, this case underscores the importance of adopting an aggressive approach to treating esophageal impaction of foreign bodies in an effort to minimize mortality, and is an unfortunate reminder of the otherwise potentially fatal consequences.
Key points 1.
Button batteries are swallowed by over 2,100 people per year in the US, affecting mostly toddlers less than 5 years old, with peak incidence in 1- and 2-year olds.
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2.
3.
Though rare, lodged button batteries can cause severe sequelae, including acute bronchopneumonia, esophagotracheal fistula, and even death. It is important for physicians to keep swallowed button battery in their list of differential diagnoses when assessing a toddler with dysphagia and anorexia.
References 1. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992;89:747–57. 2. Litovitz T. Button battery ingestions. JAMA. 1983;249(18): 2495–500. 3. Studley JGN, Linehan IP, Ogilvie AL, Dowling BL. Swallowed button batteries: is there a consensus on management? Gut. 1990;31:867–70. 4. Yardeni D, Yardeni H, Coran AG, Golladay ES. Severe esophageal damage due to button battery ingestion: can it be prevented? Pediatr Surg Int. 2004;20:496–501. 5. Blatnik DS, Toohill RJ, Lehman RH. Fatal complication from an alkaline battery foreign body in the esophagus. Ann Otol Rhinol Laryngol. 1977;86:611–5. 6. Shabino CL, Feinberg AN. Esophageal perforation secondary to alkaline battery ingestion. JACEP. 1979;8:360–2. 7. Weissberg D, Refaely Y. Foreign bodies in the esophagus. Ann Thorac Surg. 2007;84:1854–7.
